View Information Collection (IC)

View Information Collection (IC)

Pharmacies questionnaire
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire Attachment 98 – MPC Pharmacy Provider Questionnaire.docx Yes Yes Fillable Fileable

Health Immunization Management

 

6,919 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 20,203 0 0 0 0 20,203
Annual IC Time Burden (Hours) 1,010 0 0 0 0 1,010
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment 95 – MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated Attachment 95 MPC Pharmacy_Fax_AF_Packet.doc 09/14/2015
Attachment 96 – MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated Attachment 96 MPC Pharmacy_Phone_AF_Packet.doc 09/14/2015
Attachment 97 – MPC Pharmacy Provider Overflow Patient List Attachment 97 MPC Pharmacy_Overflow_Patient_List.docx 09/14/2015
Attachment 98 – MPC Durable Medical Equipment Provider Authorization Form Package Attachment 98 MPC DME AF_Packet.docx 09/14/2015
Attachment 99 – MPC Pharmacy Provider Letters, Email Templates, and Other Documents Attachment 99 MPC Pharmacy Letters.docx 09/14/2015
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.